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Red cell distribution width and mortality in pediatric sepsis
Red cell distribution width and mortality in pediatric sepsis
p-ISSN 0030-9311; e-ISSN 2338-476X; Vol.56 No.6 (2016) p. 320-4; doi: 10.14238/pI56.6.2016.320-4.
Original Article
S
Abstract epsis in children remains a major global health
Background Red cell distribution width (RDW) is a hematological problem with high morbidity and mortality.1
parameter routinely obtained as part of the complete blood count. The United States incidence was reported to
Recently, RDW has emerged as a potential independent predictor be 0.56 cases per 1,000 children per year, with
of clinical outcomes in adults with sepsis. However, RDW as a
mortality predictor in pediatric populations has not been well
deaths occurring in 4,500 cases per year.2,3 The World
established. Health Organization (WHO) reported that 70% of the
Objective To determine the relationship between RDW value 8 million deaths in children under 5 years of age in
and mortality outcomes in pediatric sepsis patients. developing countries were due to infectious diseases,
Methods We performed a cross-sectional study of 40 consecutive most of which ended with sepsis.3 Therefore, early
pediatric patients with sepsis admitted to the pICU from December
diagnosis and stratification of severity in sepsis are
2013 to March 2014. All patients’ RDW were collected within 24
hours of sepsis diagnosis. We determined the association between very important to prevent fatalities.4
RDW and hemoglobin (Hb) using Spearman’s correlation. The Biomarkers, such as interleukin (IL) and
RDW values of 11.5-14.5% were considered to be normal while procalcitonin (pCT), are often used to detect the
those >14.5% were considered to be elevated. We compared state of sepsis, determine the degree of severity,
mortality and pICU length of stay (LoS) between the normal
and elevated RDW groups using Chi-square and Mann-Whitney
and distinguish between the possible causes of
tests. sepsis. 4 Unfortunately, the availability of these
Results The median age of patients was 34 months (range examinations, especially in rural areas, is limited.5
2 months to 17 years). There were 28 (70%) male subjects.
Subjects’ median RDW was 14.8% (range 11.2-27.8%) and
was not correlated with Hb (r=0.056; p=0.73). Mortality rates
in the normal and elevated RDW groups were 40% and 45%, This study was presented at the Kongres Nasional Ilmu Kesehatan Anak XVI/
respectively. There were no significant associations between RDW KONIKA XVI (The 16th Child Health National Congress), palembang,
group and mortality (p=0.749) or pICU LoS (p=0.350). August 25 – 28, 2014.
Conclusion Unlike in adults, RDW values are not correlated
From Departments of Child Health1 and public Health2, University of
with mortality in pediatric sepsis patients. [Paediatr Indones.
Sumatera Utara Medical School/Haji Adam Malik General Hospital,
2016;56:320-4. doi: 10.14238/pi56.6.2016.320-4]. Medan, North Sumatera, Indonesia.
Red cell distribution width (RDW) has emerged family and past medical histories from parents or
as prognostic factor in adult sepsis. 6-8 Red cell guardians. We collected subjects’ RDW within
distribution width refers to the coefficient of variation 24 hours of sepsis diagnosis by taking approximately
in cell size of the circulating red blood cells (RBCs), 2 mL of venous blood using a sterile disposable syringe
and is often evaluated together with other complete and transferred it into an ethylenediaminetetraacetic
blood count parameters.7,9 However, using RDW to acid (EDTA) vial. Specimens were processed within
predict mortality in pediatric sepsis has not been well one hour using a Sysmec 4000i in the Department of
established.10 The aim of the study was to determine Clinical pathology. Subjects were divided into two
the relationship between RDW value and mortality groups based on their RDW values, the normal group
in pediatric sepsis. (RDW value 11.5 - 14.5%) and the elevated group
(RDW value > 14.5%). All subjects were followed
to evaluate outcomes, which were either death or
Methods moved to the inpatient ward care. We also recorded
subjects’ pICU LoS. Data were analyzed with SpSS for
We performed a cross-sectional study to assess for a Windows version 19.0. The association between RDW
relationship between RDW value and mortality in value and hemoglobin (Hb) level was analyzed using
sepsis patients admitted to the pICU at Haji Adam Spearman’s correlation. Comparisons of mortality and
Malik General Hospital from December 2013 to pICU LoS between the RDW groups were analyzed
March 2014. Inclusion criteria were septic children using Chi-square and Mann-Whitney tests, with a
aged 1 month to 18 years. The diagnosis of sepsis significance level of p<0.05.
was made according to The American College of
Chest physicians and The Society of Critical Care
Medicine (2005) consensus criteria, which was the Results
manifestation of systemic inflammatory response
syndrome (SIRS) with evidence of probable or During the study period, 61 septic children were
documented infection.11,12 Subjects were considered treated in the pICU. Twenty-one children were
to have SIRS if they showed at least two of the four excluded due to hematological disorders, congenital
criteria: body temperature >38°C (100.4°F) or <36°C
(96.8°F), heart rate >90 beats per minute or >2
standard deviations (SD) for age, respiratory rate >30 Table 1. Characteristics of subjects
times per minute or >2 SD for age or partial pressure Variables (n=40)
Median age, months (range) 34 (2-203)
of carbon dioxide in the arterial blood (paCO2) less
Gender, n
than 32 mmHg, and abnormal white blood cell count Male
28
12
(more than 15,000/µL or less than 5,000/µL or more Female
than 10% immature [band] forms).11 Exclusion Nutritional status, n
15
Underweight
criteria were children with hematological disorders 21
Normoweight
(such as thalassemia, sickle cell disease, leukemia, 4
Overweight
aplastic anemia, or myelodysplasia syndrome), Underlying disease, n
cardiovascular disease (congenital or acquired), or Central nervous system 6
Respiratory 7
acute hemorrhagic manifestations. Subjects’ parents Metabolic 2
provided informed consent. This study was approved Post-operative 18
by the Research Ethics Committee of the University Burn 3
Other 4
of Sumatera Utara Medical School.
Mean hemoglobin level, g/dL (SD) 11.2 (2.33)
Characteristic data, including sex, age, primary Median RDW value, % (range) 14.8 (11.2-27.8)
disease, body weight, body height, and nutritional Elevated group, n 20
status, as well as laboratory data for sepsis diagnosis Normal group, n 20
(complete blood counts, pCT, and blood cultures), Died, n 17
were obtained from medical records. We also reviewed Median PICU LoS, days (range) 6.1 (1.1-37.5)
or rheumatic heart disease, or acute hemorrhagic consecutive pediatric patients with severe sepsis and
manifestations. The median RDW was 14.8% (range septic shock revealed elevated RDW values in 67%
11.2 - 27.8%). Spearman’s correlation revealed a weak septic patients, but Spearman’s analysis showed a
correlation between RDW value and Hb (r=0.056; weak correlation between RDW value and Hb level
p=0.73). Characteristics of study subjects are shown (r = 0.08; p = 0.44).10 A retrospective study in China
in Table 1. also found elevated RDW in 58/97 (59.79%) septic
Mortality rate in the normal and elevated RDW neonates.17 Similar to previous studies, our findings
groups were 40% and 45%, respectively. There was no showed that RDW was elevated in 50% of subjects,
significant association between RDW and mortality but there was weak correlation between RDW value
(p=0.749). Elevated RDW increased the risk of and Hb level (r = 0.056) suggesting the involvement
mortality with a prevalence ratio (pR) of 1.12 (95%CI of inflammatory processes in the rise of RDW values
0.55 to 2.32) (Table 2). The median pICU LoS was in septic patients.
144 hours in the elevated group and 157.7 hours in Using RDW as a prognostic factor in critically
the normal group, but Mann-Whitney test, revealed ill adults has been well established. According to
no significant difference between groups (p=0.35). a prospective, longitudinal study of patients who
and septic shock patients held in the same country, 3. Riley C, Wheeler DS. prevention of sepsis in children:
found that the elevation of RDW values from baseline a new paradigm for public policy. Crit Care Res pract.
levels after 72 hours raised the risk of 28-day and 90- 2012;2012:1-8.
day mortality, with hazard ratios of 3.64 (95%CI 0.77 4. pierrakos C, Vincent JL. Sepsis biomarkers: a review. Crit
to 17.14; p=0.102) and 7.44 (95%CI 1.71 to 32.34), Care. 2010;14:R15.
respectively.8 5. Strimbu K, Tavel JA. What are biomarkers? Curr Opin HIV
Unlike adults, studies of RDW in pediatric sepsis AIDS. 2010;5:463-6.
are limited and with less conclusive results. In China, 6. Esper RC, Dominguez VC, Cordova LDC, Cordova JRC.
higher mortality rate was reported in septic neonates Red blood cell distribution width changes is septic patients.
with elevated RDW compared to those with normal Medicina Critica y Terapia Intensiva. 2008;22:20-5.
RDW (91.76% vs. 49.32%).16 In contrast, a prospective 7. Jo YH, Kim K, Lee JH, Kang C, Kim T, park HM, et al. Red
study of children with severe sepsis and septic shock cell distribution width is a prognostic factor in severe sepsis
reported no significant relationship between RDW and septic shock. Am J Emerg Med. 2013;31:545-8.
value and mortality, with relative risk 0.59 (95%CI 8. Kim CH, park JT, Kim EJ, Han JH, Han JS, Choi JY, et al. An
0.43 to 0.76).10 Our findings in this study showed that increase in red blood cell distribution width from baseline
the elevated RDW group had a higher mortality rate predicts mortality in patients with severe sepsis or septic
compared to the normal RDW group (45% vs. 40%, shock. Crit Care. 2013;17:R282.
respectively), but this difference was not significant (RR 9. Lanzkowsky p. Classification and diagnosis of anemia in
1.12; 95%CI 0.55 to 2.32; p=0.749). children. In: Lanzkowsky p, editor. Manual of pediatric
Our study had several limitations. First, our hematology and oncology. 5th ed. San Diego: Elsevier; 2011.
subjects had a wide variety of diseases and ranges p. 9.
of severity, so our subject population was not 10. Ramby A, Goodman D, Wald E, Weiss S. Red cell distribution
homogenous. Second, we analyzed the relationship width as a marker for severity of illness and mortality in
between RDW value and mortality after dividing pediatric sepsis. Crit Care Med. 2012;40;1-132.
subjects into elevated and normal groups, not 11. Goldstein B, Ginoir B, Randolph A. International pediatric
including the real value of RDW. sepsis consensus conference: definitions for sepsis and
In conclusion, RDW value is not correlated with organ dysfunction in pediatrics. pediatr Crit Care Med.
mortality in pediatric sepsis patients in the pICU. 2005;6:2-8.
Further studies are needed with more homogenous 12. Bone RC, Balk RA, Cerra FB, Dellinger Fp, Fein AM,
subjects and including the real value of RDW in Knaus WA, et al. Definitions for sepsis and organ failure and
statistical analysis. guidelines for the use of innovative therapies in sepsis. Chest.
1992;101:1644-55.
13. Latief A, pudjiadi AH, Somasetia DH, Alwy EH, Mulyo GD,
Conflict of Interest Kushartono H, et al. Diagnosis dan tatalaksana sepsis pada
anak. Rekomendasi ikatan dokter anak Indonesia. Jakarta:
None declared. Ikatan Dokter Anak Indonesia; 2010. p. 1-7.
14. Nurnaningsih, Setyowireni D, Rusmawatiningtyas D.
Microbial pattern in pediatrics septicaemia at pediatric
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